内镜下黏膜剥离术对早期胃癌及癌前病变的诊断价值

Diagnosis and therapeutic value of endoscopic submucosal dissection for early gastric cancer and precancerous lesions

目的观察施行内镜下黏膜剥离术(ESD)的早期胃癌及癌前病变术前活检诊断和术后病理的差异。方法回顾性分析2013年6月至2014年6月接受ESD治疗的129例术前活检诊断为早期胃癌及癌前病变的病例,通过比较采样比、钳取活检漏诊率、低估率、高估率、术前钳取活检诊断与术后病理结果的一致率等指标,观察术前活检诊断与ESD术后病理诊断之间的差异性。结果 129例患者全部成功实施ESD手术。术前活检诊断为:(1)低级别上皮内瘤变64例,平均采样比(0.68±0.3)cm/块和(1.24±0.6)cm2/块;(2)高级别上皮内瘤变62例,平均采样比(0.78±0.6)cm/块和(1.46±1.2)cm2/块;(3)早期胃癌3例,平均采样比(0.38±0.1)cm/块和(0.85±0.3)cm2/块。术前钳取活检诊断与术后病理一致率为77.5%(100/129)。其中低级别上皮内瘤变、高级别上皮内瘤变、早癌一致率分别为79.7%(51/64)、74.2%(46/62)、100%(3/3),三种级别一致率两两比较差异无统计学意义(P>0.05)。术前钳取活检的低估率为13.2%(17/129)。术前钳取活检高估率为6.2%(8/129),ESD术后病理为炎症组织占3.1%(4/129)。钳取活检对低级别上皮内瘤变高估率为13.6%(8/59),对高级别上皮内瘤变低估率为11.5%(6/52),对早癌的低估率为78.6%(11/14)。钳取活检对早癌的低估率明显高于对高级别上皮内瘤变(P<0.05)。结论内镜下钳取活检不能完全代表整个胃黏膜病变的性质。相比钳取活检,ESD具有精确诊断和对早期胃癌及癌前病变患者进行治疗的优势。对于术前钳取活检为胃黏膜低级别上皮内瘤变的病变应积极给予ESD干预。

Objective To detect the differences between preoperative and postoperative pathological biopsy in early gastric cancer and precancerous lesions which were underwent endoscopic mucosal resection（ ESD）. Methods One hundred and twenty nine patients who were diagnosed as early gastric cancer or precancerous lesions by ESD from June 2013 to June 2014 were retrospectively analyzed. The differences between preoperative pathological diagnosis and pathological diagnosis of ESD were observed by comparing the sampling ratio,forceps biopsy rate of misdiagnosis,undervalued rate,overvalued rate and concordance rate. Results One hundred and twenty nine cases were all successfully implemented of ESD operation.Among these,64 cases were low-grade intraepithelial neoplasia by preoperative biopsy,the average sampling rate was（ 0. 68 ± 0. 3） cm / piece and（ 1. 24 ± 0. 6） cm2/ piece; 62 cases were high-grade intraepithelial lesions by preoperative biopsy,the average sampling rate was（ 0. 78 ± 0. 6） cm / piece and（ 1. 46 ± 1. 2） cm2/ piece; 3cases were early gastric cancer by preoperative biopsy,the average sampling rate was（ 0. 38 ± 0. 1） cm / piece and（ 0. 85 ± 0. 3） cm2/ piece. The concordance rate was 77. 5%（ 100 /129）,and the concordance rates of low-grade intraepithelial neoplasia,high-grade intraepithelial lesions and early gastric cancer were 79. 7%（ 51 /64）,74. 2%（ 46 /62） and 100%（ 3 /3）,and there was no statistically significant pairwise comparison（ P〉0. 05）. The underestimated rate and overvalued rate were 13. 2%（ 17 /129） and 6. 2%（ 8 /129） by preoperative biopsy. The inflammatory tissue accounted for 3. 1%（ 4 /129） by ESD pathology. The overvalued rate of low grade intraepithelial neoplasiae was 13. 6%（ 8 /59） by forceps biopsy,the underestimated rates of high grade intraepithelial neoplasia and early cancer were 11. 5%（ 6 /52） and 78. 6%（ 11 /14）. The underestimated rate of forceps biopsy of early cancer was higher than that of high grade intraepithelial neoplasia（ P〈0. 05）. Conclusion Endoscopic biopsy forceps can not fully represent the whole nature of gastric lesions. Compared to the biopsy forceps,ESD has an advantage of precise diagnosis and treatment for patientswith early gastric cancer and precancerous lesions. The patients with low-grade intraepithelial neoplasia who accepted preoperative biopsy forceps should be given actively ESD interference.